Form 5305-RB (Rev. 3-2002) Page 2
Article VIII
This endorsement will be amended as necessary to comply with the provisions of the Code, the related regulations, and other
published guidance. Other amendments may be made with the consent of the persons whose signatures appear on the
contract.
Article IX
Article IX may be used for any additional provisions. If no other provisions will be added, draw a line through this space. If
provisions are added, they must comply with applicable requirements of state law and the Internal Revenue Code.
General Instructions
Section references are to the Internal
Revenue Code unless otherwise noted.
Purpose of Form
Form 5305-RB is a model annuity
endorsement that meets the
requirements of section 408A and has
been pre-approved by the IRS. A Roth
individual retirement annuity (Roth IRA)
is established after the contract, which
includes this endorsement, is fully
executed by both the individual
(annuitant) and the issuer. The contract
must be for the exclusive benefit of the
annuitant and his or her beneficiaries.
Do not file Form 5305-RB with the
IRS. Instead, keep it with your records.
Unlike contributions to traditional
individual retirement arrangements,
contributions to a Roth IRA are not
deductible from the annuitant’s gross
income; and distributions after 5 years
that are made when the annuitant is
59
1
⁄2 years of age or older or on account
of death, disability, or the purchase of a
home by a first-time homebuyer (limited
to $10,000), are not includible in gross
income. For more information on Roth
IRAs, including the required disclosures
the issuer must give the annuitant, see
Pub. 590, Individual Retirement
Arrangements (IRAs).
Definitions
IRA Conversion Contributions. IRA
Conversion Contributions are amounts
rolled over, transferred, or considered
transferred from a nonRoth IRA to a
Roth IRA. A nonRoth IRA is an individual
retirement account or annuity described
in section 408(a) or 408(b), other than a
Roth IRA.
Issuer. The issuer is the insurance
company providing the annuity contract.
The insurance company may use other
terms besides “issuer” to refer to itself,
such as, “company,”“insurer,” or “us.”
Annuitant. The annuitant is the person
who establishes the annuity contract.
The insurance company may use other
terms besides “annuitant” to refer to the
person who establishes the annuity
contract, such as, “owner,”“applicant,”
“insured,” or “you.”
Specific Instructions
Article I. The annuitant may be subject
to a 6% tax on excess contributions if
(1) contributions to other individual
retirement arrangements of the annuitant
have been made for the same tax year,
(2) the annuitant’s adjusted gross
income exceeds the applicable limits in
Article II for the tax year, or (3) the
annuitant’s and spouse’s compensation
is less than the amount contributed by
or on behalf of them for the tax year.
The annuitant should see the
disclosure statement or Pub. 590 for
more information.
Article V. This article describes how
distributions will be made from the Roth
IRA after the annuitant’s death. Elections
made pursuant to this article should be
reviewed periodically to ensure they
correspond to the annuitant’s intent.
Under paragraph 2 of Article V, the
annuitant’s spouse is treated as the
owner of the Roth IRA upon the death of
the annuitant, rather than as the
beneficiary. If the spouse is to be treated
as the beneficiary, and not the owner, an
overriding provision should be added to
Article IX.
Article IX. Article IX and any that follow
it may incorporate additional provisions
that are agreed to by the annuitant and
issuer to complete the contract. They
may include, for example, definitions,
investment powers, voting rights,
exculpatory provisions, amendment and
termination, removal of the issuer,
issuer’s fees, state law requirements,
beginning date of distributions,
accepting only cash, treatment of
excess contributions, prohibited
transactions with the annuitant, etc.
Attach additional pages if necessary.
Form 5305-RB (Rev. 3-2002)
